MEDICARE: THOMAS W MCCULLOH DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	1878	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407879661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS W MCCULLOH DO

Provider Business Mailing Address
First Line	:	1104 WALNUT DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-2353
Country	:	US
Telephone Number	:	580-226-0543
Fax Number	:	580-226-2284

Provider Business Practice Location Address
First Line	:	1104 WALNUT DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-2353
Country	:	US
Telephone Number	:	580-226-0543
Fax Number	:	580-226-2284

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	10/24/2022

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